Hepatitis C screening strategies in hemodialysis patients

doi:10.1053/ajkd.2001.25199

American Journal of Kidney Diseases

Volume 38, Issue 1, July 2001, Pages 91-97

https://doi.org/10.1053/ajkd.2001.25199 Get rights and content

Abstract

Hepatitis C virus (HCV) infection is common in patients undergoing chronic hemodialysis, with an estimated yearly incidence of 0.2% and prevalence between 8% and 10%. Although a screening strategy based on alanine aminotransferase (ALT) values is currently recommended, this strategy has not been evaluated for cost-effectiveness compared with other potential screening strategies. A comparison therefore was made using a decision-analysis model of a simulated cohort of 5,000 hemodialysis patients followed up for 5 years. Using direct medical costs, three strategies were evaluated, including: (1) ALT values with confirmatory testing (biochemical), (2) serial enzyme-linked immunosorbent and strip immunoblot assay testing (serological), and (3) polymerase chain reaction (viral). Under baseline assumptions, the per-patient cost of screening hemodialysis patients for HCV was $378 for biochemical-based testing, $195 for serological-based testing, and $696 for viral-based testing. Our model was robust when varying the costs of testing, as well as the incidence and prevalence of HCV infection. Results of sensitivity analysis by varying costs, HCV incidence, and HCV prevalence indicated that serological-based screening was less costly than biochemical testing. Biochemical testing was in turn less costly than viral-based screening. Serological-based testing was also more effective in the diagnosis of de novo HCV infection, with a likelihood ratio of 85, in contrast to the likelihood ratio of 44 with biochemical-based testing using viral-based screening as the gold standard. A serological-based screening strategy is less costly and more effective than biochemical-based screening in the diagnosis of de novo HCV infection. Serological-based screening should be considered for HCV screening in hemodialysis populations. © 2001 by the National Kidney Foundation, Inc.

Section snippets

Study design

A decision-cost analysis was performed using a simulation model of 5,000 hemodialysis patients who were followed up for 5 years.17, 18, 19, 20 A period of 5 years was arbitrarily chosen because the natural history of patients infected with HCV is not well understood, although substantial liver disease is seen in patients referred for renal transplantation. MEDLINE was searched between the years 1992 and 2000 using different combinations of the following key words: hepatitis C, hemodialysis, and

Results

Using baseline biochemical ($6.31), serological (ELISA, $20.30; SIA, $58.30), and viral ($74.20) test costs, serological-based screening was the least costly screening strategy. The cost of screening per patient in our hypothetical hemodialysis cohort was $382 for biochemical-based screening, $195 for serological-based testing, and $696 for viral-based screening. Total costs for screening the hypothetical cohort for the 5 years were $1,908,524, $975,965, and $3,480,506 using the biochemical,

Discussion

HCV infection has important implications. Infected patients must be identified to encourage alcohol abstinence and be advised of their potential for transmission. For instance, infected patients should not share toothbrushes, razors, and combs or hairbrushes with close contacts to avoid transmission.⁹ Hemodialysis patients continue to be at increased risk for HCV infection despite the implementation of universal precautions and decreased need for blood products with the use of erythropoietin.³⁹

Acknowledgements

The authors thank David Ly for data collection.

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: P.M. and H.F.Y. contributed equally as senior authors.

: Supported in part by award no. DK 02450 from the National Institute of Diabetes and Digestive and Kidney Diseases (H.F.Y.); American Association for the Study of Liver Diseases/Schering Award (S.S.); and National Service Research Award no. DK07180-2 from the National Institutes of Health (S.S.).

^★: Address reprint requests to Sammy Saab, MD, Division of Digestive Diseases, 44-138 CHS (MC 168417), UCLA Medical Center, 10833 Le Conte Ave, Los Angeles, CA 90095. E-mail: [email protected]

^★★: 0272-6386/01/3801-0014$35.00/0

View full text

Original InvestigationsHepatitis C screening strategies in hemodialysis patients★,★★

Abstract

Section snippets

Study design

Results

Discussion

Acknowledgements

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Clin Liver Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Diagn Microbiol Infect Dis

Kidney Int

Lancet

Am J Gastroenterol

National surveillance of dialysis-associated diseases in the United States, 1997

Semin Dial

Hepatitis C virus infection in medical personnel after needlestick accident

Hepatology

Retrospective study on the impact of hepatitis C virus infection on kidney transplant patients over 20 years

Transplantation

Impaired kidney transplant survival in patients with antibodies to hepatitis C virus

Nephrol Dial Transplant

Histopathological features of hepatitis C in renal transplant candidates

Transplantation

Recommendation for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease

MMWR Morb Mortal Wkly Rep

Impact of decreased serum transaminase levels on the evaluation of viral hepatitis in hemodialysis patients

Nephron

Hypoaminotransferasemia in patients undergoing long-term hemodialysis: Clinical and biochemical appraisal

Gastroenterology

Quantitative assessment of HCV load in chronic hemodialysis patients: A cross-sectional survey

Nephron

Abnormal alanine aminotransferase activity reflects exposure to hepatitis C virus in haemodialysis patients

Nephrol Dial Transplant

Original Investigations
Hepatitis C screening strategies in hemodialysis patients★,★★